MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES.
PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP.
I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Saturday, May 19, 2007

Absolute Manna From Heaven - A Renal Case, Examine This Pt's Abdomen

This case was one I got during my mock , A 56 yr gentleman of Asian descent, he had warty fingers , looked pale peripherally, with an oblique scar in RIF,a palpable mass which is dull to percussion below it .Another scar on the left lateral aspect of the abdo extending all the way to the back, a scar of about 3cm just below the umbilicus, 2 symmetrical scars just above the bikini line oneither side, had a non working brachio-cephalic fistula on the left,a non-working radio-cephalic fistula on the left, scars of previous perma-cath on rt pectoral region, moon face, buffalo hump,had gum hypertrophy,centripetal obesity with no ascites.

I think from this you can visualise my patient, he had all the signs, but you needed to put them in order to make a good perfomance, This time I went for the jugular:

Mr XYZ has ESRF and has had a renal transplant in the RIF which is working well,He has gum hypetrophy which evidence of previous Cyclosporin use and warty fingers which is evidence of previous Azathioprine use.He also has a buffalo hump and centripetal deposition of adipose tissue which is evidence of long term steroidal use.He has previous scars from Tenckhoff catheters for peritoneal dialysis. He has also had haemodialysis using the permacath and from abrachiocephalic fistula which is no longer working, He has no ascites and his abdomen is non tender

I would like to comlplete my examination by checking Temp chart, BP, urine dip for glycosuria, fundoscopy

Q: What do you think is the cause of renal failureA:Being of Asian descent Diabetes is highest on my list but could also be due to hypertension, glomerulonephritis, adult polycystic kidney dse, nephrocalcinosis

Q: You mentioned about all scars except one on the left abdo , what was it for?A: Maybe some unrelated abdo surgery, or complications from CAPD or left renal surgery.

Q: Can you tell us the indications for nephrectomy in APCKD?A: Very large kidneys, recurrent abdo pain, recurrent haemorrhage into cysts and malihnant change

I later found that this pt had APCKD and had undergone lt nephrectomy with RIF transplant